The Effect Of Coaxial Biopsy Technique On CT-guided Percutaneous Puncture Biopsy Of The Lung

Background and objectiveLung shadow is a common and difficult clinical problem. With the popularity of CT examination and improvement of health consciousness, more and more people perform the chest CT regularly. As a result, a large number of patients with pulmonary shadow are observed, some of which are at early stage of lung cancer. Although surgery is considered as a good method, it’s very important to make clear the property of lung shadow as soon as possible. For some kinds of benign diseases, it’s very hard to make sure the diagnosis only with image, which brings great challenges for the respiratory physicians.Biopsy is the gold standard of diagnosis for the pulmonary shadow. However, it is an invasive examination. We are used to get lung tissue by surgery, by which we could get enough tissue, and cut the diseased lung tissue as well. However, it is really a big trauma and a waste of medical resources. So we should find another kind of examination with minimum injury for diagnosis.According to different route of entry, there are two methods to obtain pathology specimen. One is through bronchoscopy from the respiratory tract, the second is to use a needle puncture through the skin to achieve lesion. Each method has advantages and disadvantages. Which kind of method would be selected depends on the position of lesion. Though it has a low risk from the respiratory tract, patients would get more suffering during the examination.The pathological tissue volume is relatively small for subsequent pathological diagnosis. False negative is relatively more, surgical success rate is lower and the consumption of health care costs more. On the contrary, percutaneous puncture has a high risk for patient but it could reduce the pain. We could also get more tissues, less false negative result, higher achievement ratio of surgery and less medical resource. More generally speaking, percutaneous puncture lung biopsy is used when the lesion locates in the peripheral, bronchoscopy biopsy is used when the lesion located in the central. In fact, the operation approach is also decided by operator according to the specific situation.If the lesion has been expanded to the main bronchus, we usually choose bronchoscope to achieve higher success rate and minor waste of medical resource. While it’s difficult to perform bronchoscope, percutaneous puncture is another choice.According to different guiding modes, percutaneous puncture of pulmonary biopsy could be divided into ultrasound-guidance, fluoroscopic-guidance and CT-guidance. No X-ray influence and real-time guidance are the advantages of echo-guidance; however, it is only useful when a lesion is close to the chest wall. Once the first needle puncture in pneumothorax, the lesion would leave the chest wall and additional puncture is failed. Fluroscopic guidance offers a real-time guidance and a better vision. However, surgeon and patient should suffer more X-ray. There is no radiation influence to operator with CT guidance. It can guide the extremely small lesion but not real-time. CT guidance is the most commonly used at present.At the beginning of the percutaneous biopsy conducted by CT, operator often use simple biopsy needle. Along with the surgical development and accumulated experience, someone has started to use coaxial biopsy needle. Coaxial biopsy technique is performed using a simple biopsy needle and trocar needle which is shorter and matching the former. Operator makes location on the patient with the trocar before traditional way. After specimen is obtained, the biopsy needle is extracted from the coaxial needle which is left in the body. Then the tissue could be achieved from the biopsy needle. The traditional technique is performed using only simple biopsy needle which is pulled out of the body after one puncture. Turn for the needle is drawn out from the patient. And it should be re-needling at a second time. The operator need to insert the biopsy needle again.Our research is to explore the differences between coaxial biopsy and simple biopsy needle biopsy technology mainly from the following six aspects.1. It is a difficult point of percutaneous lung biopsy that operator is easily failed to obtain specimen from small pulmonary nodule. Coaxial biopsy technique seems to increase the stability of operation. Can it really increase the success ratio of surgery?2. It is also a difficult point of percutaneous lung biopsy that operator is easily failed to obtain specimen from deeper pulmonary nodule. Can coaxial biopsy technique increase the success ratio of surgery?3. Pneumothorax is a common complication of percutaneous lung biopsy operation. Although coaxial needle can avoid re-needling the pleura when additional specimen is needed, it increased the diameter of the needle track that leads the lung communicating with the outside world for some time in the process of puncture. It is unclear that coaxial biopsy technique would increase or reduce the incidence of pneumothorax complication. Are there any differences between a single puncture and repeated puncture?4. Hemoptysis is also a common complication of percutaneous lung biopsy operation. It inevitably causes a puncture aperture increases when putting coaxial needle on the ordinary biopsy needle. The puncture aperture increase and this coat protection contradict each other, but it is not clear how hemoptysis changes as a result. Are there any differences between a single puncture and repeated puncture? Are operator inclined to repeated puncture in order to achieve a better operation effect while performing coaxial biopsy technology?5. There is a radical difference between two kinds of operation procedure. Coaxial biopsy technology adds a step to insert coaxial needle to the lesion to save time on evaluating puncture location for multiple biopsy. Which kinds of operation method can be more convenient to complete the surgery?6. CT inevitably causes radiation damage to patient. We unify the use of low dose scanning way. Could the application of the coaxial biopsy technology reduce radiation to patient?With those questions, we design this study.MethodsWe collected 224 cases of patients with unexplained lung shadow from April 2011 to December 2014, which randomly divided into an intervention group and a control group. We used the coaxial biopsy in intervention group, while we used the traditional needle biopsy in control group. One operator performed all the operations, who had successfully completed more than 50 operations independently using the two surgery types, to exclude interferences from different surgical proficiency. We used just one surgical assistant in different groups, to ensure identical collaborations. All the operations were performed at the same place to exclude interferences of place. We used the same surgical tool kit and surgical tools, excluding appliances interference, the same timekeeper to minimize timing errors and the same CT operating technician to exclude interference fromt technician proficiency. All the operations were performed during 17:30 to 19:00, to exclude the time interference. One observed and recorded postoperative hemoptysis. There was no significantly difference in sex, age, lesion diameter, depth between the two groups. All CT scanners are set to unified parameters with 5 mm thick,1.5 pitch, bed-speed 15 mm per second,30mA,120kV. We tried to reduce the radiation doses through minimizing the scale of CT scanning. All the measures above were intended to ensure that the data were comparable between the two groups.Judgment for the successful operation:If the obtained specimens are macroscopic tissue strips, and pathological report records that pathological tissue is observed under the microscope, we define this operation success. If the obtained specimens are not macroscopic tissue strips, or pathological report records that alveolus tissue is observed under the microscope, we define this operation failure. Subjects observed include cases of patients with smaller and deeper lesions.Once gas is observed in the last CT scan, regardless of quantity and symptom, pneumothorax complication is defined. Subjects observed include cases of patients with no underlying diseases and normal pulmonary function.If macroscopic hemoptysis is observed during operating procedures or within 48 hours after operation, regardless of quantity, it is recorded as a positive event. Cough just after the puncture or bleeding blot in CT scan but no hemoptysis, it is recorded as a negative event. Subjects observed include cases of patients with no hemoptysis,no underlying diseases and normal pulmonary function before operation.Surgical time is defined as the time between local anesthesia finished, when the operator holds the needle ready to puncture the skin and the last scan finished. All the patients whose specimens are successfully acquired from surgery were included in observation.The radiation dose is defined as the total exam dose-length product the patient received after the surgery. Value provided by CT machine is considered as standard. All the patients whose samples are successfully acquired from surgery were included in observation.All data is analysed using SPSS 19.0 statistical software. For count data statistics, X2 test is used when the theoretical frequency is greater than 5. Fisher’s exact probability method is used When the theoretical frequency is less than 5. α=0.05, P < 0.05 difference has statistical significance. The measurement data of statistics are descriptived as mean ±standard deviation (X±S). The measurement data goes through the normal test and F test. If variance, using both the sample meter t test, if the variance is not neat, the adoption both sample meter t’inspection, inspection level of α= 0.05, P< 0.05.Result1. For small nodule biopsy success rate, there is a significant difference between the two groups, the experimental operation success rate (96.7%) versus the control group (73.3%).2. For deep lesion biopsy success rate, there is a significant difference between the two groups, the experimental operation success rate (98.33%) versus the control group (81.25%).3. The incidence of complications for pneumothorax has a significant difference between the two groups, experimental group of pneumothorax rate (20.0%), lower than the control group (33.3%). In a single biopsy case, two groups has no significant difference between the incidence of pneumothorax. In the case of multiple needle puncture, the incidence of pneumothorax is significant different between the two groups, experimental group (21.4%), versus the control group (47.5%). When using a coaxial, the prevalence of pneumothorax of single puncture biopsy has no significant difference compared with multiple puncture group. When using a simple single puncture biopsy needle technique, incidence of pneumothorax has significant difference between single needle puncture group (47.5%) and multiple puncture(26%).4. For the incidence of haemoptysis complication, there is significant difference between experimental group (18.0%) and control group (31.1%). In a single biopsy cases, two groups has no significant difference between the incidence of haemoptysis. In the case of multiple needle puncture, significant difference exists between two groups:experimental group (17.14%) versus control group (47.5%). As far as possible for a definitive diagnosis, the operator performs coaxial puncture technology is more intended to use multiple needle puncture than those who perform simple needle technology. The difference between them is significant. When using a coaxial needle biopsy technique, the prevalence of haemoptysis difference is not significant between single puncture group and multiple puncture group. When using a simple single needle biopsy technique, compared with single puncture group, multiple puncture group shows a significant higher incidence of hemoptysis: (47.5%) versus (18%).5. The operation time of successful operation in the experiment group are 702.72±68.95 seconds, the time in the control group are 901.96±62.91 seconds. The difference between the two groups is significant. The operation time of successful operation of the experimental group is shorter than the control group.6. The TDLP of successful operation in the experiment group is 29.88±3.73mGy.cm, the TDLP in the control group is 37.47±4.45mGy.cm. The difference between the two groups is significant. The radiation dose of successful in experimental group is less than that of the control group.ConclusionThe success rate for difficult puncture lesion of operation of coaxial biopsy technique is higher than the simple biopsy needle biopsy technique, it can reduce the probability of occurrence of pneumothorax and hemoptysis complications, reduce the patient radiation doses, save the operation time, and the technology has the advantages of low cost as well as simple operation. The coaxial biopsy technique need only coaxial technique based on the traditional simple needle biopsy technology, is worth clinical promotion.